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PubMedDate not supplied

Decision matrix for selection of patients for a home infusion therapy program.

Managed care and escalating healthcare costs have affected all aspects of clinical practice. Today's practitioners must evaluate each patient and clinical situation to select the appropriate intravenous delivery venue to improve the chances of producing a satisfactory outcome. The IV venue discussed in this article will focus on the key elements of identifying patients who will benefit from receiving pharmacomedical services in a home infusion therapy program.

Drug Therapy↗
PubMed1998

Diabetes care management: a managed care approach.

A Diabetes Care Management program was developed by PrimeCare, a network model HMO, to improve quality of life health outcomes and reduce the costs of medical care for its members with diabetes. The HMO used a systems-based approach to communicate information about appropriate self-management and standards of care to members and physicians. The focus of the program was to educate and encourage patients to self-manage their illness, and to partner with physicians, other health care providers and community organizations to achieve improved quality of life, clinical and financial results. Clinical process indicators were used to measure results of interventions. Significant increases in the percentage of participants receiving glycosylated hemoglobin (HbA1c) tests, retinal eye exams and lipid panel tests were achieved.

Diabetes Mellitus↗
PubMed1998

Making managed care work for people with disabilities.

Over two years ago, with states increasingly moving to contract with managed care organizations for the care of people with disabilities and chronic illnesses, States of Health explored the concerns of some of these health care consumers and their families. Worries centered on the health plans' lack of experience serving disabled and chronically ill patients; the prevalence of a medical model of care, which undervalues services that enable a person to maintain a high quality of daily life; and incentives to cut costs that would result in inappropriate or negligent care. Little has been resolved since then. A few health plans--mostly small specialty plans--serve as oases of best practices, but their attitudes and ways of operating are far from adoption across the board. Advocates argue that the best targeted, most reliable consumer protections involve consumers themselves in the planning, design, and implementation of managed care programs.

Community Health Planning↗
PubMed2003

Guideline recommendations for treatment of schizophrenia: the impact of managed care.

BACKGROUND: Medicaid-managed care has been shown to reduce the number and length of psychiatric hospitalizations, but little is known about the clinical and social consequences of such managed care programs. The purpose of this study was to compare the treatment of schizophrenia for disabled Medicaid beneficiaries who were and were not enrolled in managed care. METHODS: This was a prospective observational study of patients who sought care for a psychiatric crisis from June 7, 1997, to May 13, 1999. Patients were followed up for 6 months. Inpatient and outpatient mental health facilities in Massachusetts were studied. The participants included 420 adult Medicaid beneficiaries, aged 24 to 64 years, who were treated for schizophrenia; 784 eligible beneficiaries were originally contacted and invited to participate (53.6% response). A private managed behavioral health care organization administered the Medicaid mental health benefit for about half the patients in the study. The other half were enrolled in the dually insured fee-for-service Medicare/Medicaid plan. The main outcome measures were adherence to the Schizophrenia Patient Outcomes Research Team treatment recommendations from inpatient and outpatient medical records, self-reported quality of interpersonal interactions between patient and clinician, self-reported care experiences and outcomes, and clinician-reported outcomes. RESULTS: There were no differences between the managed care plan and the unmanaged fee-for-service plan in adherence to the schizophrenia treatment guidelines. However, much outpatient care in both programs was inconsistent with treatment guidelines. Inpatient treatment was far more likely to conform to guidelines than outpatient treatment. Patient ratings of their care were positive and not different between plans. Clinical outcome and health-related quality of life were not different between plans. CONCLUSIONS: A major change in Massachusetts in the way mental health care is organized and financed had neither a negative nor a positive effect on care quality. However, adherence to nationally accepted guidelines for care was only modest, suggesting a need to improve the delivery of treatment to the most disabled highest-risk adults with schizophrenia.

Adult↗
PubMed2002

Risk selection among SSI enrollees in TennCare.

The issue of risk selection is especially important for states that enroll blind and disabled beneficiaries of Supplemental Security Income (SSI) in Medicaid managed care. SSI beneficiaries have persistent needs for care, have a wide variety of chronic conditions, and often need atypical and complex services. Risk selection occurs when the health care needs of beneficiaries enrolled in a specific plan differ systematically from the needs of the overall beneficiary population and payments do not reflect those needs. We assess the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare. Using claims data containing fee-for-service expenditures prior to enrollment in managed care, we find substantial evidence of persistent risk selection among plans. Results are robust to most alternative measures of risk selection for most plans.

Aid to Families with Dependent Children↗
PubMed1998

Oncology services: the Department of Defense perspective.

The Department of Defense (DoD) military health system has responsibility for providing medical care for more than 8 million beneficiaries. This article discusses initiatives related to both the providing and purchasing of oncology services. A description of health care coverage under TRICARE, the Department's managed care program, which utilizes military treatment facilities and civilian health care providers, is provided. Participation in clinical trials by the DoD beneficiaries, oncology services in military treatment facilities, quality management programs, cancer research, and the development of new technologies to enhance early cancer detection are presented. Access to research trials and new technologies is necessary for a comprehensive approach to cancer care. Clinical trials have been the vehicle by which the oncology community developed most of its formal clinical evidence for the efficacy of various treatment approaches. The Department participates in clinical trials through cooperative group membership or affiliation. Through an interagency agreement with the National Cancer Institute, DoD beneficiaries have available the option of participating in NCI-sponsored clinical trials through the direct military care system or through civilian care with reimbursement for approved protocols nationwide. The DoD has been actively involved in breast cancer research since 1992 and prostate and ovarian cancer research since 1997. The goals of the cancer research programs are to expedite and facilitate breakthroughs in research, support innovative, and exploratory ideas with a vision to foster new directions, address neglected issues, and bring new investigators into the research arena. The program incorporates the consumer perspective by involving consumers in the decision-making process. The DoD health care system trains experts in the management of cancer patients and provides a multidisciplinary approach to care through the direct military health care system or through network providers as part of the TRICARE system. Although cost containment is key, the delivery of high quality health care that is easily accessible is a primary goal of the military health system. Provision of a comprehensive benefits package that includes a spectrum of care and employing outcomes measurements to evaluate care that is appropriate for the patient's disease is essential.

Clinical Trials as Topic↗
PubMed2000

The effects of medical group practice and physician payment methods on costs of care.

OBJECTIVE: To assess the effects of payment methods on the costs of care in medical group practices. DATA SOURCES: Eighty-six clinics providing services for a Blue Cross managed care program during 1995. The clinics were analyzed to determine the relationship between payment methods and cost of care. Cost and patient data were obtained from Blue Cross records, and medical group practice clinic data were obtained by a survey of those organizations. STUDY DESIGN: The effects of clinic and physician payment methods on per member per year (PMPY) adjusted patient costs are evaluated using a two-stage regression model. Patient costs are adjusted for differences in payment schedules; patient age, gender, and ACG; clinic organizational variables are included as explanatory variables. DATA COLLECTION: Patient cost data were extracted from Blue Cross claims files, and patient and physician data from their enrollee and provider data banks. Medical group practice data were obtained by a mailed survey with telephone follow-up. PRINCIPAL FINDINGS: Capitation payment is correlated with lower patient care costs. When combined with fee-for-service with withhold provisions, this effect is smaller indicating that these two clinic payment methods are not interchangeable. Clinics with more physician compensation based on measures of resource use or based on some share of the net revenue of the clinic have lower patient care costs than those with more compensation related to productivity or based on salary. Salary compensation is strongly associated with higher costs. The use of physician profiles and clinical guidelines is associated with lower costs, but referral management systems have no such effect. The lower cost clinics are the smaller, multispecialty clinics. CONCLUSIONS: This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care. However, the methods by which that influence is manifest is not clear. Although the organizational structure of clinics and their use of managed care programs appear to play a role, this influence is less than expected.

Adolescent↗
PubMed1996

Characteristics of managed care patients in a psychiatric emergency service.

Managed care programs establish procedures to help their patients avoid use of psychiatric emergency services. To determine whether managed care patients who do visit the emergency service do so primarily for hospitalization and have briefer contacts with the service because of preapproval for hospitalization, records were examined for 293 patients who visited a psychiatric emergency service; 69 were enrolled in a managed care plan. The findings did not confirm the expectations: many managed care patients received crisis services and were referred for outpatient care. The non-managed-care group had more psychotic and substance use disorders, required more emergency community intervention, and had more previous psychiatric hospitalizations.

Ambulatory Care↗
PubMed1997

Diabetes management: improving care in HMO and community settings.

Developing an effective, quality-driven disease management program for the treatment of patients with diabetes has become essential for MCOs, which cover the majority of American individuals suffering from this condition. At Cedars-Sinai Medical Center in Los Angeles, the Diabetes Managed Care Program was developed and implemented in an effort to provide a model for similar diabetes management initiatives in both managed health care plans and community settings.

California↗
PubMed1997

A study on decentralizing from acute care to home care settings in Germany.

Although it is generally accepted in Germany that decentralizing towards home care settings can improve the efficiency and effectiveness of health care, a coherent policy toward decentralization has not been developed yet. A variety of elements of the traditional German health care system have limited the opportunities for decentralizing. Separation between health care and social services, separation between acute care and medical rehabilitation and separation between ambulatory care and hospital care were rather strict, prohibiting development of a comprehensive infrastructure of professional support for home care as well as the hospital financing scheme. Recent reform measures in Germany in the field of health care policy and social policy partly have tackled these problems. The introduction of long-term care insurance might provide the chance for a better infrastructure and more comprehensive usage of professional support for home care, although it is not without risks, and integration of long-term care insurance in the health policy sector lacks coherence. While reforms of the hospital financing scheme and an entitlement of hospitals to provide one-day-surgery and post-discharge treatment will decrease the likelihood that hospitals keep patients in order to fill their beds, the extent to which hospitals will make use of these new instruments remains doubtful at present. Increased competition between sickness funds could open opportunities for prudent 'managed care' as part of 'managed competition', and strengthening of home care might be part of managed care programs. At present it is not clear, however, whether sickness funds will be entitled to compete through usage of managed care mechanisms. Other elements of recent health care reforms were counterproductive as far as decentralizing towards home care is concerned. Especially global budgets on honorariums for office-based doctors and on volumes of prescribed drugs might create incentives for inefficient and ineffective referrals to hospitals.

Cost Control↗
PubMed1996

Any-willing provider laws: point and counter point.

Health care costs in the United States are placing businesses in a competitive disadvantage in the international market. Health Care is now the third highest cost category in US corporations after salaries and raw materials. Alternative Health Care delivery systems in the form of managed care have become popular mechanism to promote cost control. A critical element in most managed care programs is a limitation of freedom of choice of provider. As a result, physicians are being deliberately excluded from some managed care plans. Legislation called "Any Willing Provider Statutes" is being enacted in many areas to prohibit such actions. The authors outline the advantages and disadvantages of such legislation and discuss the economic implications for hospitals and the private practice of medicine. They also examine the impact "any willing provider" legislation will have on patient care and detail how this legislation involves who is going to control the practice of medicine in the years ahead. An examination of the American model should assist others involved with health care planning and regulating medical practice.

Consumer Advocacy↗
PubMedDate not supplied

Foster care and Medicaid managed care.

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.

Child↗
PubMed1997

Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators.

OBJECTIVE: This study examined predictors of hospital readmission to determine whether readmissions can serve as a quality indicator for an inpatient psychiatric service. METHOD: A series of 255 patients consecutively admitted to any of seven psychiatric hospitals in a regional managed care program were followed to determine whether they were readmitted within 6 months of discharge. Case managers assessed patients with the use of a reliable outcome management/decision support system designed for acute psychiatric services. RESULTS: Patients with greater impairment in self-care, more severe symptoms, and more persistent illnesses were more likely to be readmitted than other patients. Suicidal patients were less likely to be readmitted. There was no evidence to suggest that poor hospital outcome or premature discharge was associated with readmission either within 30 days or within 6 months. CONCLUSIONS: Although patients at risk for hospital admission can be identified, it does not appear that the success of the hospital intervention per se influences the likelihood of readmission. Use of readmission rates as quality indicators for hospital care providers is not recommended.

Acute Disease↗
PubMed1994

Compensation of radiologists.

The compensation of radiologists for professional services to patients has shifted in the past half century from a strong reliance on hospital billing and payment to a pattern of financial independence of radiology groups. The laws and regulations creating the Medicare program were instrumental in spurring the transition for many. With the advent of managed care programs, employer self-insurance for health costs and pending state and federal health reform efforts, radiology compensation patterns are likely to undergo further changes to make them compatible with new payment mechanisms.

Fees, Medical↗